Peripartum cardiomyopathy: clinical and therapeutic aspects.

Peripartum cardiomyopathy is an under-recognized form of dilated cardiomyopathy of unknown cause and is associated with excess morbidity and mortality in women of childbearing age. Incidence of peripartum cardiomyopathy ranges from 1 in 1,300 to 1 in 15,000 pregnancies. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Multiparity, twin births, advanced maternal age, preeclampsia, gestational hypertension, and black race are known risk factors. The exact cause of peripartum cardiomyopathy is unclear. The clinical presentation of patients with peripartum cardiomyopathy is similar to that of patients with systolic congestive heart failure. Little is known about the therapy of this disease, and the medical treatment is limited to the use of drugs for symptomatic control. Prospective, randomized, double-blind studies are needed to define the role of immunosuppressive treatment and to evaluate the role of conventional treatment of dilated cardiomyopathy in reducing the mortality rate of peripartum cardiomyopathy. About half the patients of peripartum cardiomyopathy recover without any complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival. The risk of developing peripartum cardiomyopathy in subsequent pregnancies remains high. The clinical and therapeutic aspects of the peripartum cardiomyopathy are discussed.

Prognostic value of serum cardiac troponin I in ambulatory patients with chronic renal failure undergoing long-term hemodialysis: a two-year outcome analysis.

OBJECTIVES: We sought to evaluate the prognostic value of cardiac troponin I (cTnI) in asymptomatic, ambulatory patients with chronic renal failure treated with long-term hemodialysis. BACKGROUND: Smaller, short-term follow-up studies on this subject have given conflicting results. METHODS: A total of 126 ambulatory patients with chronic renal failure treated with long-term hemodialysis were followed for two years for all-cause mortality, cardiac mortality, all-cause hospital admissions and cardiac hospital admissions. Serum cTnI was measured before dialysis at the time of study entry. RESULTS: One hundred two patients had normal serum levels of cTnI (< or =0.03 ng/ml) and 24 patients had elevated levels (0.015 +/- 0.007 vs. 0.053 +/- 0.029 ng/ml, p < 0.0001). No significant difference in all-cause mortality (20 vs. 4 deaths), cardiac mortality (4 vs. 1 death), all-cause hospital admissions (1.74 +/- 1.72 vs. 1.25 +/- 1.19 admissions/patient) or cardiac admissions (0.52 +/- 0.89 vs. 0.33 +/- 0.76 admissions/patient) was present between the patients with normal cTnI levels and those with elevated cTnI levels. Serum cTnI was not significantly different between patients who died versus those who survived (0.022 +/- 0.019 vs. 0.022 +/- 0.021 ng/ml). Serum cTnI was not an independent predictor of all-cause mortality, cardiac mortality, all-cause admissions or cardiac admissions. Age (older) and serum albumin (lower) were independent predictors of all-cause mortality, whereas a history of myocardial infarction was an independent predictor of cardiac mortality. Serum sodium (lower) was an independent predictor of all-cause hospital admissions, whereas hypertension and previous myocardial infarction were independent predictors of cardiac admissions. The best predictors of the time to death were age (older) and serum sodium level (lower), irrespective of the serum cTnI levels. CONCLUSIONS: Cardiac troponin I has a limited role in predicting mortality and hospital admissions in asymptomatic patients with chronic renal failure treated with long-term hemodialysis.

Pneumocystis carinii pneumonia in pregnancy.

OBJECTIVE: To report five new cases of Pneumocystis carinii pneumonia (PCP) and to review and analyze the existing reports on the subject. METHOD: Five new cases of PCP during pregnancy are described. The cases, case series, and related articles on the subject in the English language were identified through a comprehensive MEDLINE search and reviewed. RESULTS: More than 80% of women with AIDS are of reproductive age, and PCP is the most common cause of AIDS-related death in pregnant women in the United States. Among 22 reviewed cases, the mortality rate was 50% (11 of 22 patients), which is higher than that usually reported for HIV-infected individuals with PCP. Respiratory failure developed in 13 patients (59%), and mechanical ventilation was therefore required, and the survival rate in patients requiring mechanical ventilation was 31%. Maternal and fetal outcomes were better in cases of PCP during the third trimester of the pregnancy. A variety of treatment regimens were used, including sulfamethoxazole-trimethoprim (SXT) alone or in combination with pentamidine, steroids, and eflornithine. The survival rate in patients treated with SXT alone was 71% (5 of 7 patients) and for those treated with SXT and steroids was 60% (3 of 5 patients), with an overall survival rate in both groups of 66.6% (8 of 12 patients). CONCLUSION: PCP has a more aggressive course during pregnancy, with increased morbidity and mortality. Maternal and fetal outcomes remain dismal. Treatment with SXT, compared to other therapies, may result in an improved outcome. Withholding appropriate PCP prophylaxis may adversely affect maternal and fetal outcomes.

Age-related differences in the use of cardiac medications in patients with coronary artery disease.

BACKGROUND: Benefits of aspirin and beta-blocker use in patients with coronary artery disease and angiotensin-converting enzyme (ACE) inhibitors in those with left ventricular systolic dysfunction are well documented in all age groups. OBJECTIVE: To investigate whether aspirin, beta-blockers, and ACE inhibitors are equally used in geriatric (> or =65 years) versus younger (<65 years) patients with coronary artery disease. SETTING: University-affiliated major academic hospital. METHODS: Records of 402 patients with coronary artery disease were analyzed for use of aspirin, beta-blockers, and ACE inhibitors. One hundred thirty patients with contraindications to use of these agents were excluded. RESULTS: Of 272 study patients, 85% were using aspirin and 71% beta-blockers. Among the patients with left ventricular systolic dysfunction, 79% were using ACE inhibitors. One hundred forty-seven patients were of geriatric age, whereas 125 were of younger age. No significant difference in the use of aspirin (82% versus 89%, P = 0.10), beta-blockers (71% versus 70%, P = 0.85), or ACE inhibitors (86% versus 69%, P = 0.13) was found between geriatric and younger patients. This lack of difference in use of cardiac medications between geriatric and younger patients persisted on gender-based subgroup analysis. On decade-of-age-based analysis, aspirin use was not equally distributed among all the decades of age (P < 0.005), but beta-blocker use was. CONCLUSION: Results of this study demonstrate equal use of aspirin, beta-blockers, and ACE inhibitors in geriatric versus younger patients with coronary artery disease. Aspirin use was not equally distributed among all the decades of age.

Acute ventricular rate control in atrial fibrillation: IV combination of diltiazem and digoxin vs. IV diltiazem alone.

OBJECTIVE: To analyze the efficacy of an IV combination of diltiazem and digoxin vs IV diltiazem alone for acute ventricular rate control in patients with atrial fibrillation. DESIGN: Prospective, randomized, open-label study. PATIENTS AND METHODS: Fifty-two patients with atrial fibrillation and uncontrolled ventricular rates were randomized to receive either an IV combination of diltiazem and digoxin or IV diltiazem alone and were observed for 12 h. The successful rate control was defined as a ventricular rate < 100 beats per minute (bpm) persisting for 1 h or conversion to sinus rhythm. The loss of rate control was defined as an increase in the ventricular rate to > 100 bpm persistently for > 30 min or rebound to atrial fibrillation. RESULTS: In both treatment arms (n = 26 each), all patients achieved successful and comparable ventricular rate control at 12 h. The mean (+/- SD) time taken to achieve successful rate control was shorter in the combination arm (15 +/- 16 vs. 22 +/- 22 min). Six patients in the combination arm and 11 in the diltiazem-alone arm experienced episodes of loss of rate control. This loss in the combination arm was less than that in the diltiazem-alone arm (14 vs 39 episodes; p = 0.05). The loss of rate control per patient in the combination arm was also less than that in the diltiazem-alone arm (2.0 +/- 1.0 vs. 3.5 +/- 1.9 episodes per patient; p = 0.04). CONCLUSIONS: This study demonstrates that in patients with atrial fibrillation who have a rapid ventricular response, the IV combination of diltiazem and digoxin results in a more efficacious ventricular rate control with fewer fluctuations than that achieved by therapy with IV diltiazem alone.

HIV-Related pulmonary hypertension: analytic review of 131 cases.

OBJECTIVE: To report two new cases of HIV-related pulmonary hypertension and to review and analyze the existing reports on the subject. METHOD: Two new cases of HIV-related pulmonary hypertension are described, and the cases, case series, and related articles on the subject in all languages were identified through a comprehensive MEDLINE search. RESULTS: Among the 131 reviewed cases, 54% were male, and the age range was 2 to 56 years (mean, 33 years). The interval between the diagnosis of HIV disease and the diagnosis of pulmonary hypertension was 33 months. In 82% of cases, pulmonary hypertension was related solely to HIV infection. Presenting symptoms were progressive shortness of breath (85%), pedal edema (30%), nonproductive cough (19%), fatigue (13%), syncope or near-syncope (12%), and chest pain (7%). The mean (+/- SD) pulmonary arterial systolic BP was 67 +/- 18 mm Hg (n = 116), and diastolic BP was 40+/-11 mm Hg (n = 39). Pulmonary vascular resistance was 983+/-420 dyne. s. cm(-5) (n = 29). Chest radiographs demonstrated cardiomegaly (72%) and pulmonary artery prominence (71%). Right ventricular hypertrophy was the most common electrocardiographic finding (67%). Dilatation of the right heart chambers was the most common echocardiographic finding (98%). Plexogenic pulmonary arteriopathy was the most common histopathology (78%). Pulmonary function tests demonstrated mild restrictive patterns with variably reduced diffusing capacities. The responses to vasodilator agents and antiretroviral therapy was variable. Sixty-six patients died during a median follow-up period of 8 months. The median length of time from diagnosis to death was 6 months. CONCLUSION: HIV infection is an independent risk factor for the development of pulmonary hypertension. The appearance of unexplained cardiopulmonary symptoms in HIV-infected individuals should suggest pulmonary hypertension.

Stenotrophomonas maltophilia endocarditis of prosthetic aortic valve: report of a case and review of literature.

Stenotrophomonas Maltophilia (previously known as Xanthomonas maltophilia and Pseudomonas maltophilia ) is an aerobic, nonfermenting, gram-negative bacillus, which has emerged as a serious nosocomial pathogen in patients with compromised immunity. It is a rare cause of endocarditis with only 20 cases previously reported in medical literature. The risk factors associated with S maltophilia endocarditis include intravenous drug abuse, dental treatment, previous cardiac surgery, and infected intravascular devices. S maltophilia is resistant to multiple antibiotics, which leads to frequent therapeutic failures. Although the optimal antibiotic treatment for S maltophilia endocarditis remains unknown, most of the patients received 2 or more antibiotics. We report a case of S maltophilia endocarditis of prosthetic aortic valve, associated with a painless aortic dissection, that responded well to a combination of ciprofloxacin and chloramphenicol. The literature is reviewed to elaborate the disease characteristics, the treatments used, and the prognosis of the S maltophilia endocarditis.

Extramammary Paget's disease.

Extramammary Paget's disease (EMPD) is an uncommon but distinctive tumor. The lesion is defined as an intra-epidermal neoplasm. The lesion may be accompanied by an invasive adenocarcinoma or in situ adenocarcinoma of apocrine glands. Visceral carcinoma may also coexist or develop. Definitive diagnosis requires biopsy of the lesion and immunohistochemical staining. In most cases of noninvasive or minimally invasive EMPD, surgical resection with clear margins and careful follow-up are recommended, since the recurrence rate is high. We review the literature and report two cases of EMPD, one involving the perineal-scrotal area and the other involving the perianal area.

Systemic toxicity from ocular homatropine.

Toxidromes are well known to emergency physicians. An unclear or incomplete history and subtle findings on physical examination make the diagnosis of poisonings challenging. This article reports a patient who had an acute onset of visual hallucinations, pressured speech, and mania. Although she denied taking any medications, she was ultimately diagnosed as having anticholinergic toxicity. On further questioning of family members, it was discovered that she was being treated for anterior uveitis with 5% homatropine. This case illustrates the potential role of ocular medications in systemic toxicity. Patients often do not consider eyedrops to be medications, and their use may be overlooked in the medical history. It also is important to educate patients and medical staff in methods to minimize systemic toxicity when using ocular medication.

Repair of retinal detachment associated with proliferative vitreoretinopathy using perfluoroperhydrophenanthrene (Vitreon). Vitreon Study Group.

A total of 140 consecutive patients underwent repair of retinal detachment associated with grade C2 to D3 proliferative vitreoretinopathy with perfluoroperhydrophenanthrene (Vitreon) as an intraoperative hydrokinetic tool. In seven patients the Vitreon was left in the eye for extended tamponade. Intraoperative reattachment was obtained in 98% of patients. At the final follow-up examination (mean 7 months) 84% of retinas remained attached, and 92% of patients had stable or improved visual acuity. Vitreon was found to be safe and effective in the repair of complicated retinal detachments. No complications were directly related to Vitreon when used intraoperatively or when left in the eye for extended tamponade.

Perfluoroperhydrophenanthrene (Vitreon) in the management of giant retinal tears: results of a collaborative study.

Fifty cases of retinal detachment with a giant retinal tear were managed using perfluoroperhydrophenanthrene (Vitreon) as an intraoperative and postoperative tool. The giant tear was less than 180 degrees in 76% of the eyes, greater than 180 degrees in 22%, and greater than 270 degrees in 2%. Proliferative vitreoretinopathy was present in 40%. Vitreon was used only intraoperatively in 84% of the eyes, and was left in 16% for up to 4 weeks. Intraoperative retinal reattachment was achieved in 98%. Retinal attachment was maintained in 88%, with a mean follow up of 8.6 months. Postoperative visual acuity was better than 20/400 in 52%. Postoperative complications included cataract in 23%, choroidal effusion in 2%, hypotony in 4%, and recurrent retinal detachment with proliferative vitreoretinopathy in 26%.

Perfluoroperhydrophenanthrene (Vitreon) as a short-term vitreous substitute after complex vitreoretinal surgery.

Forty-one eyes underwent surgery for complex vitreoretinal disease, with perfluoroperhydrophenanthrene (Vitreon) used as an intraoperative tool and postoperative vitreous substitute. Postoperative use of Vitreon ranged from 3 days to 9 weeks (mean, 3.3 weeks). All retinas were reattached intraoperatively; 73% remained attached after the initial surgery. The final macular attachment rate was 100% after additional surgery. Four eyes that received a combination of Vitreon and silicone oil for simultaneous superior and inferior tamponade were successfully reattached after the initial procedure. Visual acuity improved or remained stable in 80% of the eyes. No toxic effects directly attributable to Vitreon were observed. Mean follow up was 9 months.

Use of perfluoroperhydrophenanthrene in the management of posteriorly dislocated crystalline and intraocular lenses.

We describe a series of 28 patients in whom a posteriorly dislocated crystalline or intraocular lens was successfully removed with the intraoperative use of perfluoroperhydrophenanthrene (Vitreon), a heavy liquid perfluorocarbon. The Vitreon was used to float the lens into the midvitreous cavity, thereby avoiding hazardous micromanipulation with intraocular instruments in the macular area. In addition, the Vitreon served to protect the posterior retina by keeping the posteriorly dislocated lens fragments from falling backward onto the posterior pole as the lens was being removed from the eye. Postoperative visual acuity improved in 73% of the patients, remained the same in 15%, and worsened in 12%.